Classification of Ovarian Cancer
• Epithelial tumors—80%. The most common type of histologic ovarian carcinomais epithelial cancer, which predominantly occurs in postmenopausal women. These include serous, mucinous, Brenner, endometrioid, and clear cell tumors. The most common malignant epithelial cell type is serous.
• Germ cell tumors—15%. Another histologic type of ovarian cancer is the germ celltumor, which predominantly occurs in teenagers. Examples are dysgerminoma, endo-dermal sinus tumors, teratomas, and choriocarcinoma. The most common malignant germ cell type is dysgerminoma. It is uniquely x-ray sensitive.
• Stromal tumors—5%. The third type of ovarian tumor is the stromal tumor, which isfunctionally active. These include granulosa-theca cell tumors, which secrete estrogen and can cause bleeding from endometrial hyperplasia and Sertoli-Leydig cell tumors, which secrete testosterone and can produce masculinization syndromes. Patients with stromal tumors usually present with early stage disease and are treated either with removal of the involved adnexa (for patients who desire further fertility) or a TAH and BSO (if their family has been completed). They metastasize infrequently, and then they require chemotherapy (vincristine, actinomycin, and Cytoxan).
• Metastatic tumor. These are cancers from a primary site other than the ovary. The most common sources are the endometrium, GI tract, and breast. Krukenberg tumors are mucin-producing tumors from the stomach or breast metastatic to the ovary.
GYN Triad
Serous Carcinoma
• Postmenopausal woman
• Pelvic mass
• ↑ CEA or CA-125 level
GYN Triad
Choriocarcinoma
• Postmenopausal woman
• Pelvic mass
• ↑ hCG level
GYN Triad
Sertoli-Leydig Tumor
• Postmenopausal pelvic mass
• Masculinization
• ↑ testosterone level
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USMLE Step 2 l Gynecology
GYN Triad
Endometrial Carcinoma
Metastatic to Ovaries
• Postmenopausal woman with bilateral pelvic masses
• Postmenopausal bleeding
• Enlarged uterus
| • Mucinous
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| • Serous | |||||||||
| Epithelial | |||||||||
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| • | Endometrioid | ||||||
| • | Clear cell | ||||||||
| • | Brenner | ||||||||
| • Mature teratoma | |||||||||
| • Dysgerminoma | |||||||||
| Germ cell | |||||||||
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| • Endodermal sinus | ||||||||
| • Immature teratoma | |||||||||
| • Choriocarcinoma | |||||||||
| • Monodermal | • Fibroma | ||||||||
| • Thecoma | |||||||||
| • | Granulosa | ||||||||
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| Stroma and sex cords |
| • | Sertoli-Leydig | |||||
| • | Hilus cell | ||||||||
| • | Lipid cell | ||||||||
| • | Stromal luteoma | ||||||||
| • Pregnancy luteoma | |||||||||
Figure II-5-2. Overview of Ovarian Oncology
Table II-5-2. Classic Histology Types of Ovarian Cancer
| Type | Percentage | Age Group |
| Epithelial | 80% | Older |
| Germ cell | 15% | Young |
| Stromal | 5% | All |
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Tumor Markers
• CA-125 (cancer antigen 125) and CEA (carcinoembryonic antigen) should also bedrawn for the possibility of ovarian epithelial cancer.
• LDH, hCG, anda-fetoprotein should be drawn for the possibility of germ cell tumors.
• Estrogen and testosterone should be drawn for the possibility of stromal tumors.
Staging. Staging is surgical.
Stage I: Spread limited to the ovaries
IA. Limited to one ovary, capsule intact, negative cytology
IB. Limited to both ovaries, capsules intact, negative cytology
IC. One or both ovaries but ruptured capsule, positive cytology
Stage II: Extension to the pelvis
IIA. Extension to uterus or tubes
IIB. Extension to other pelvic structures
IIC. Extension to pelvis with positive cytology
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Chapter 5 l Disorders of the Ovaries and Oviducts
Stage III: Peritoneal metastases or positive nodes. This is the most common stage at diagnosis.
IIIA. Microscopic peritoneal metastases
IIIB. Macroscopic peritoneal metastases ≤2 cm IIIC. Macroscopic peritoneal metastases >2 cm
Stage IV: Distant metastases
IVA. Involves bladder or rectum IVB. Distant metastasis
Management. A surgical exploration should follow preoperative studies and medical evalua-tion. If abdominal or pelvic CT scan shows no evidence of ascites or spread to the abdominal cavity, and if the surgeon is an experienced laparoscopist, then the evaluation could be per-formed laparoscopically. At the time of surgery, a unilateral salpingo-oophorectomy (USO) is done and sent for frozen section.
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Benign Histology. If the patient is not a good surgical candidate or the patient desires to main-tain her uterus and contralateral ovary, a USO is sufficient treatment. If the USO by frozen section is benign and the patient is a good surgical candidate, then a TAH and BSO may be performed even though it is benign disease because the uterus and ovaries are not unusual sites of pathology in a woman.
Malignant Histology. In this case, a debulking procedure (cytoreduction) should be performed.
This procedure consists of a TAH and BSO, omentectomy, and bowel resection, if necessary.
Postoperative chemotherapy (carboplatin and Taxol) should be administered.
Follow-Up. If the final pathology report of the enlarged adnexa was benign, the patient can befollowed up in the office on a yearly basis for regular examination. If the pathology report was carcinoma, then she would be followed up every 3 months for the first 2 years and then every 6 months for the next 2 years with follow-up of the CA-125 tumor marker.
Borderline Cancers. Another entity of ovarian cancer is the borderline tumors also known astumors of low malignant potential. These are characterized by no invasion of the basement membrane and can also be treated conservatively.
• Conservative surgery. A patient who desires further fertility with a unilateral border-line cancer of the ovary can be treated with a USO with preservation of the uterus and the opposite adnexa.
• Aggressive surgery. If the patient has completed her family then the most acceptabletreatment would be a TAH and BSO.
• Chemotherapy. Patients with borderline cancer of the ovary do not require chemo-therapy unless they have metastasis, and this is a rare occurrence.
Adnexal Mass With Ascites
A 65-year-old woman is referred for evaluation of abdominal distention and ascites and an adnexal mass. The patient has noted abdominal distention for the past 6 months, and on pelvic examination there is a 7-cm irregular and solid mass in the cul-de-sac, which is palpable by rectovaginal examination.
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GYN Triad
Ovarian Carcinoma with Peritoneal Metastasis
• Postmenopausal bilateral pelvic masses
• Weight gain, anorexia
• Abdominal “shifting dullness”
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Definition. Ascites is an abdominal accumulation of fluid in the peritoneal cavity, which usu-ally causes abdominal distention.
Differential Diagnosis. The etiology of ascites can be multifactorial and includes heart, kidney,and liver disease and ovarian cancer. In a female patient with ascites, ovarian carcinoma must always be considered. Although the etiology of ovarian carcinoma is not known, ovulation inhi-bition, as occurs with OCPs or pregnancy, does decrease the risk of epithelial ovarian cancer. Meigs syndrome is the triad of ascites, pleural effusion, and benign ovarian fibroma.
Laboratory Abnormalities/Diagnostic Criteria. In a patient with an adnexal mass and ascites,an abdominal pelvic CT scan should be ordered for evaluation of the upper abdomen. The most common method of ovarian carcinoma spread is by peritoneal dissemination (exfolia-tion) and is commonly seen metastatic to the omentum and to the GI tract. The cause of death of patients with advanced ovarian carcinoma is bowel obstruction.
Management Steps
• Surgical staging. After an abdominal pelvic CT scan confirms the presence of ascitesand the adnexal mass, an exploratory laparotomy and surgical staging should be per-formed. A salpingo-oophorectomy of the enlarged ovary should be done and sent for frozen section evaluation.
• Debulking surgery. If ovarian carcinoma is confirmed, then a debulking (cytoreduc-tive) surgical procedure should be performed. This procedure usually includes a TAH, BSO, omentectomy, and, frequently, bowel resection.
• Chemotherapy. Postoperatively patients should be treated with 6 courses of a standardchemotherapy regimen, which includes Taxol and carboplatin. Patients are followed
with the tumor marker CA-125.
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| Gestational Trophoblastic Neoplasia | 6 | |
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